Use of fine-needle aspiration cytology and frozen section in the management of nodular goiters

Utility of Routine Frozen Section of Thyroid Nodules Classified as Follicular Neoplasm

OBJECTIVES

To evaluate the diagnostic performance of frozen section in thyroid nodules classified as follicular neoplasm.

METHODS

A diagnostic test meta-analysis was designed. Studies that assessed frozen section in patients with thyroid nodules and a fine-needle aspiration biopsy result of Bethesda IV were selected. The outcomes measured were the number of false- and true-positive and -negative results. We used the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) instrument for methodological quality assessment and a bivariate mixed-effects regression framework and a likelihood-based estimation of the exact binomial approach.

RESULTS

Forty-six studies from 1991 to 2018 were included. Most studies had moderate methodological quality. The overall sensitivity and specificity were 43% (95% confidence internal [CI], 0.34-0.53) and 100% (95% CI, 0.99-1.00), respectively. The hierarchic summary receiver operating characteristic curve showed an area under the curve of 0.91 (95% CI, 0.80-0.97).

CONCLUSIONS

Frozen section demonstrates moderate diagnostic performance in patients with follicular neoplasm, and its utility for making intraoperative decisions is limited. Its routine use should be discouraged.

Fine-Needle Aspiration Versus Frozen Section in the Evaluation of Malignant Thyroid Nodules in Patients With the Diagnosis of Suspicious for Malignancy or Malignancy by Fine-Needle Aspiration

Context.—

The Bethesda System for Reporting Thyroid Cytopathology recommends against the use of intraoperative frozen section (FS) during lobectomy of a thyroid nodule with a fine-needle aspiration (FNA) diagnosis of malignant. Bethesda recommendations for FS in the FNA category of suspicious for malignancy (SFM) is less well-defined. In some institutions in China, FS examination is performed during lobectomy even for FNA-proven malignant cases.

Objective.—

—To compare the efficacy of FNA versus FS in the evaluation of malignant thyroid lesions.

Design.—

A 3-year retrospective analysis from a single institution was performed on cases with an FNA diagnosis of SFM or malignant with subsequent FS examination during thyroidectomy. The results of FNA and FS findings were compared to the final thyroidectomy pathology.

Results.—

—A total of 5832 thyroidectomy procedures were performed: 1265 cases had FNA and FS results available. Fine-needle aspiration gave a diagnosis of SFM to 306 cases and a diagnosis of malignant to 821 cases. Of the SFM cases, 10.5% (32 of 306) had benign/indeterminate, 4.6% (14 of 306) suspicious, and 84.9% (260 of 306) malignant FS results. Final pathology showed 56.3% (18 of 32), 64.3% (9 of 14), and 100% (260 of 260) malignancy rates, respectively. For the malignant FNA group, 10.0% (82 of 821) had benign/indeterminate, 4.4% (36 of 821) suspicious, and 85.6% (703 of 821) malignant FS results. The final pathology showed 96.4% (79 of 82), 97.2% (35 of 36), and 99.9% (702 of 703) malignancy rates, respectively.

Conclusions.—

Frozen section should not be performed for the malignant FNA category because FS evaluation may result in 10% falsely negative findings. Performing FS for SFM may be better justified; however, more than half of FS cases read as benign in this category had malignant final pathology. Therefore, caution should be taken for FS results even in the SFM group.

Thyroid follicular neoplasm: analysis by fine needle aspiration cytology, frozen section, and histopathology

We performed a retrospective analysis of follicular neoplasm data obtained from frozen section examinations of thyroid nodules. A total of 5,660 patients underwent preoperative neck ultrasonography and fine-needle aspiration cytology (FNAC), surgical treatment, and follow-up at a medical institute. Patients with papillary thyroid microcarcinoma were excluded from this study. In 971 cases, frozen section examination was performed during the surgical treatment of follicular neoplasm that was diagnosed via FNAC. Thyroid malignancies were histologically confirmed in 25.1% of cases (244/971). Among the patients with papillary thyroid carcinoma, 45 were diagnosed with the follicular variant of papillary thyroid carcinomas (27.4%). The diagnostic sensitivity of frozen section for the nonfollicular variant of papillary thyroid carcinoma was better than that for the follicular variant of papillary thyroid carcinoma (89.1% versus 78.9%; P = 0.1023). For 12 cases the diagnosis was atypical follicular adenomas. The diagnostic accuracy of frozen section in cases of follicular neoplasm was 76.9% with a sensitivity of 84.8% and a specificity of 98.9%. In conclusion, our analysis revealed high rates of accuracy when using frozen tissue sections for early diagnosis and treatment of follicular neoplasm; thus, an early decision to extent of surgery prevents a risky follow-up surgery.

Liquid-based FNAC of the thyroid: a 4-year survey with SurePath

BACKGROUND

The aims of this study were to analyze cytomorphological features of Tripath PREP (BD SurePath, Burlington, NC) preparations in thyroid nodules and to examine adequacy and accuracy of SurePath and frozen sections for both clinical outcome and histological diagnosis when applicable.

METHODS

Gathered during a period of 4 years, 712 SurePath specimens of the thyroid were included. Histological (n = 207) or clinical follow-up (n = 505) was available in all cases. During the same period, 253 frozen sections of surgical thyroid resection specimens were also assessed. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated.

RESULTS

Sensitivity was 77% for SurePath and 29% for frozen section; specificity was 81% for SurePath and 100% for frozen section; accuracy was 80% for SurePath and 90% for frozen section. One hundred seventy-eight (25%) SurePath patients were considered unsatisfactory for diagnosis. In this study, sensitivity, specificity, and accuracy were comparable for SurePath and other reported results of liquid-based thyroid cytology. Presence of free colloid or pure cystic changes favored a benign diagnosis. Cellular smears with nuclear atypia of papillary carcinoma allowed an overt diagnosis of malignancy.

CONCLUSIONS

The authors concluded that SurePath is a reliable technique for assessment of thyroid nodules and offers the advantage of easy identification of colloid and atypical nuclei. Supplementary frozen section analysis should be limited to an FNAC diagnosis of suspicious for papillary carcinoma.

A meta-analysis of comparing fine-needle aspiration and frozen section for evaluating thyroid nodules

The literature on comparing fine-needle aspiration (FNA) and frozen section for evaluating thyroid nodules was reviewed. Publications on this subject were divided into three groups (follicular lesions, non-follicular lesions and thyroid lesions, not otherwise specified). A meta-analysis was done to compare sensitivity, specificity, and positive and negative predictive values between FNA and frozen section diagnoses. For follicular lesions, FNA was much more sensitive but less specific, with lower positive predictive value than frozen section. FNA and frozen section are virtually identical in all parameters of accuracy in evaluating thyroid nodules that are not follicular lesions. The third group of publications that did not separate/specify follicular lesions from non-follicular lesions was non-contributory.

Fine-needle aspiration may miss a third of all malignancy in palpable thyroid nodules: a comprehensive literature review

BACKGROUND

Fine-needle aspiration (FNA) is currently the primary diagnostic procedure in diagnosing thyroid malignancy and guides surgeons on patient selection for thyroidectomy for thyroid nodules. Diagnostic sensitivity is reported to be approximately 80%; however, patients with negative FNA results do not necessarily undergo surgery and are often not considered in statistical analysis. This may lead to bias in previous reported sensitivity of FNA. The aim of this study was to assess the diagnostic performance attributes of FNA based on a comprehensive review and summary of previous literature.

METHODS

A comprehensive review of published literature from 1966 to 2005 was performed, using structured selection and appraisal methods to include all studies that have assessed the sensitivity of FNA for detecting thyroid malignancy in palpable thyroid nodules. A statistical modeling study was designed to estimate the possible true sensitivity and specificity of FNA.

RESULTS

Twelve studies fulfilled inclusion criteria and were included in the review. Only 1 study had greater than 25% of patients with negative FNA results who proceeded to thyroidectomy. Statistical modeling indicated that the sensitivity of FNA is highly dependent on the risk of malignancy in the patients with negative FNA results who did not undergo thyroidectomy; in the "same risk" scenario, where the risk of malignancy in the whole group with negative FNA result was assumed to be the same as that in patients with negative FNA results who underwent surgical biopsy; sensitivity could be as low as 66% (confidence interval [CI]: 65-68%).

CONCLUSION

Based on existing reports, the true diagnostic attributes of FNA for thyroid malignancy in palpable nodules are uncertain and FNA could miss up to a third of all thyroid malignancy. Further research is required to investigate the incidence of malignancy in FNA negative cases and to determine the additive effect of clinical judgment.

Intraoperative pathologic examination: cost effectiveness and clinical value in patients with cytologic diagnosis of cellular follicular thyroid lesion

OBJECTIVE

Routine use of intraoperative pathologic examination (IOPE), including frozen section (FS) and scrape preparation cytology (SPC), during diagnostic thyroid lobectomy continues to be a source of controversy. We sought to better delineate the usefulness and cost-benefit ratio of IOPE in the context of cytologically diagnosed cellular follicular lesion (CFL) or follicular neoplasm (FN).

DESIGN

Records of 205 patients who underwent thyroidectomy for cytologically diagnosed FN or CFL between 1997 and 2005 were retrospectively reviewed. IOPE results, patient demographics, and tumor characteristics were correlated to final histopathologic diagnoses. Sensitivity, specificity, predictive values, accuracy, and costs of IOPE were calculated.

MAIN OUTCOME

IOPE correctly identified 3 of 16 follicular carcinomas and 9 of 36 papillary carcinomas. Sensitivity, specificity, and accuracy were 23%, 99%, and 78%, respectively. On univariate analysis, malignancy risk among follicular nodules did not correlate with age, gender, or nodule size. On multivariate analysis, nodule size was predictive of malignancy (p < 0.05). Over the entire patient series, routine IOPE resulted in a net cost savings of $74,304.33.

CONCLUSIONS

IOPE reduced costs and limited the number of completion thyroidectomies necessary. IOPE is specific, cost effective, and of minimal additional risk when performed routinely for patients with CFL or FN.

Utilidad de la biopsia intraoperatoria en el tratamiento quirúrgico del nódulo tiroideo

OBJECTIVE

To present our experience of the use of frozen section (FS) in the operative management of thyroid nodules and determine the utility of this procedure when deciding the extent of thyroidectomy.

PATIENTS AND METHOD

We performed a prospective and comparative study. The FS of patients who underwent surgery for thyroid nodules between 1995 and 2002 were evaluated. The results were compared with those of fine-needle aspiration cytology (FNA) and definitive biopsy. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of both FNA and FS were calculated.

RESULTS

There were 469 thyroidectomies and 179 FS were performed. The results obtained for FNA and FS were, respectively: PPV: 100%/100%; NPV: 89%/90%; diagnostic accuracy: 89.5%/91%. When only "follicular hyperplasia" was included as the cytologic diagnosis, the PPV and NPV for FS were 100% and 86.7%, respectively.

CONCLUSION

The diagnostic accuracy of FNAC and FS is similar. In cases of follicular hyperplasia, the sensitivity of FS is too low to rule out malignancy.

Role of Fine-needle Aspiration Biopsy and Frozen Section in the Management of Papillary Thyroid Carcinoma Subtypes

Since fine-needle aspiration biopsy (FNAB) was introduced, the value of frozen section (FS) has been questioned. This study compares FNAB and FS sensitivities among the usual form of papillary thyroid cancer (uPTC) and variants of PTC such as tall cell (tcPTC), follicular (fPTC), and Hurthle cell (HcPTC). A total of 257 patients who underwent preoperative FNAB, intraoperative FS, and thyroidectomy for PTC were, randomly selected from a database of a university teaching hospital in Toronto. There were 218 females (84.8%) and 39 males (15.2%), from 19 to 89 years of age (mean of 44 years), having uPTC (n = 212), fPTC (n = 24), HcPTC (n = 14), and tcPTC (n = 7). Data were analyzed using chi2 test. Sensitivities were calculated by division of true positives and by the sum of true positives and false negatives. True positives had to reflect a conclusive diagnosis of cancer. The FNAB sensitivities were uPTC (39.2%), fPTC (25%), HcPTC (42.9%), tcPTC (85.7%), similar to FS sensitivities (p = 0.497) for uPTC (44.3%), fPTC (16.7%), HcPTC (42.9%), and tcPTC (71.4%). Use of FS following FNAB increased sensitivities for uPTC to 56.1%, fPTC to 29.2%, and tcPTC to 100%. In addition, FS did not increase FNAB sensitivity in HcPTC. Combination FNAB plus FS failed in 43.9% of uPTC, 70.8% of fPTC, and 57.1% of HcPTC. We concluded that FNAB and FS sensitivity vary with PTC subtype and are still necessary for selection and treatment. The recognition of morphologic subtypes of PTC from the FNAB could optimize the selection of patients for intraoperative FS, enhance the preoperative assessment of prognosis, facilitate the surgical planning, and simplify the preparation of postoperative adjuvant therapy.